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O. Box 45053 Jacksonville FL 32232-5053 Part A Overpayment Redetermination Part B of A Redetermination outpatient hosp SNF therapy Part B of A Overpayment Redetermination Part A Reopening attach form UB-04 2. Puerto Rico Form revised 5/18/2017 REQUEST FOR A REDETERMINATION/REOPENING OF PART A MEDICARE CLAIM Note This is for an appeal and not to be used when requesting a claim adjustment Submit requests to Part A Redetermination Inpatient SNF IRF IPF First Coast Service Options Inc. Medicare...
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